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The Schizoid Disturbance

The term “schizoid” has two meanings. It denotes (1) a tendency of the individual to withdraw from reality and (2) a split in the unity of the personality. Each aspect is a reflection of the other. These two variables are a measure of the emotional health or illness of the individual.

In emotional health the personality is unified and in full contact with reality. In schizophrenia the personality is divided and withdrawn from reality. Between the two lies the broad range of the schizoid states in which the withdrawal from reality is manifested by some degree of emotional detachment and the unity of the personality is maintained by the power of rational thought. Figure 4 illustrates these relationships.

FIG. 4 Contact with Reality Unity of the Personality

This schema also includes the psychic disorders known as the neuroses. The neuroses, A. P. Moyes writes, are a “relatively benign group of personality disturbances,” in which the “personality remains socially organized.”⁴ This is not to say that the neurotic individual has a well-integrated personality. Every neurotic problem stems from a conflict in the personality which splits its unity to some extent and reduces its contact with reality. In both the neuroses and the psychoses there is an evasion of reality; the difference, as Freud points out, is that the neurotic ignores reality while the psychotic denies it. However, every withdrawal or evasion of reality is an expression of the schizoid disturbance.

Against the background of a seemingly adjusted personality, neurotic symptoms have a dramatic quality which dominates the clinical picture. A neurotic phobia, obsession, or compulsion is often so striking that it focuses the attention to the exclusion of the underlying schizoid split. In this situation, treatment tends to be directed to the symptom rather than to the more deep-seated personality problem. Such an approach is necessarily less effective than one which sees the symptoms as a manifestation of the basic conflict between the ego and the body and directs the therapeutic effort to the healing of this split. In Figure 4, I have placed the neuroses in parentheses to indicate that they are included in the schizoid phenomenon.

One reason for the increasing recognition of the schizoid problem is the shift of psychiatric interest from the symptom to the personality. Psychotherapists are growing increasingly aware of the lack of feeling, the emotional detachment, and the depersonalization of their patients. It is now generally recognized that the schizoid condition with its deep-seated anxieties is directly responsible for symptom formation. Important as the symptom is to the disturbed individual, it occupies a secondary role in current psychological thinking. If symptoms are alleviated in psychotherapy without regard to the underlying schizoid disturbance, the treatment is regarded as supportive and the results are considered to be only temporary. To the degree, however, that the schizoid split can be overcome, the improvement in the patient occurs on all levels of his personality.

While psychotherapists are conscious of the widespread incidence of schizoid tendencies in the population, the general public is ignorant of this disorder. The average person still thinks in terms of neurotic symptoms and assumes that in the absence of an alarming symptom, everything is all right. The consequences of this attitude may be disastrous, as in the case of a young person who commits suicide without warning or suffers a so-called nervous breakdown. But even if no tragedy occurs, the effects of the schizoid disturbance are so serious that we cannot overlook its presence in neurotic behavior or wait until a crisis occurs.

Late adolescence is a critical period for the schizoid individual. The strong sexual feelings that flood his body at this time often undermine an adjustment which he had previously been able to maintain. Many young people find themselves unable to complete their high school studies. Others do so with an effort, but run into trouble in the first years of college. On the surface the problem may appear as described below.

A teenager who had done fairly well at school runs into difficulty with his studies. His marks drop, his interest lags, he becomes restless, and he starts running around with “bad” characters. His parents ascribe his behavior to a lack of discipline, poor will power, rebelliousness, or the mood of today's youngsters. They may close their eyes to his difficulties in the hope that he will outgrow them. This rarely happens. They may berate the young person and attempt to coerce him into a more responsible attitude. This generally fails. In the end, they reluctantly accept the idea that seemingly bright children become “dropouts,” that some are just naturally “floaters,” that many young people from good backgrounds engage in destructive or delinquent activities; and they give up any attempt to comprehend the attitude of their adolescent children.

The schizoid individual cannot describe his problem. As far back as he can remember, he has always had some difficulty. He knows that something is wrong, but it is a vague knowledge that he cannot put into meaningful words. Without the understanding of his parents or teachers, he resigns himself to an inner desperation. He may find others who share his distress and with whom he can establish a rapport based on a mode of existence that is “different.” He can even rationalize his behavior and gain some sense of superiority by proclaiming that he is not a “square.”

I shall present four cases to illustrate some of the different forms the schizoid disturbance can take and the common elements in all four. In each case the disturbance was severe enough to require therapeutic help. In all cases, it was ignored or overlooked until a crisis occurred.

VARIETIES OF SCHIZOID PERSONALITY AND BEHAVIOR

1. Jack was a young man, twenty-two years old when I first saw him. He had graduated high school at eighteen, after which he spent a year singing folk songs in coffee houses. He followed this with two years in the army, then drifted from one job to another.

Jack's crisis occurred after his release from the army. In the company of his friends, he took some mescaline, a hallucinogenic drug. The result was an emotional experience that shocked him. He said:

I had hallucinations that are impossible to describe. I saw women in every conceivable stimulating position. But when I came out of it, I hated myself. My guilt about sex confuses me. The strange thing is that I claim to be unconventional, left wing, no sex limitations, et cetera. I can reason this out, but I can't get away from the feeling of guilt. It frightens and depresses me.

This experience, induced by the drug, broke down Jack's adjustment. The schizoid tendency in his personality, which he had managed to keep under control, broke through into the definitive symptoms of the disorder. He described them as follows:

a. Fright—“At times the fright is so severe that I can't be left alone. I think I'm just plain afraid of losing my mind.”

b. Hypochondriasis—“Every little pimple, scratch, pain, et cetera, scares me to death. I immediately think of cancer, syphilis…”

c. Detachment—“Once I felt like I was slipping from reality, sort of removed; and within the past few weeks, I've felt removed almost constantly, as though I'm somewhere else watching myself.”

When the symptoms appear with the intensity described above, the diagnosis is easy. However, it would be a mistake to assume that there had been no previous evidence of the schizoid disturbance. Jack had experienced severe fright in the form of night terrors when he was very young. And even as a child he struggled with feelings of unreality. He related that:

As early as I can remember [six or seven years], I've always felt different, but I was constantly convinced by my parents that this was normal. In grade school I usually felt sort of strange—example: sitting in class watching the other pupils and wondering if they felt the same confusion as I did.

The unfortunate aspect of this problem was that no one in Jack's immediate entourage seemed to understand his difficulties. “My parents and friends convinced me that this feeling [of being different and strange] was a normal feeling,” he said. Jack's experience in this respect seems to be the rule. Even night terrors are often passed off as “normal” experiences, which the child will outgrow.

Jack's body showed the typical schizoid features. It was thin, tight, and rigid, with an underdeveloped musculature, limited motility, and restricted respiration. It was an unalive looking body, from which Jack had dissociated his ego long ago. He had never seriously engaged in sports or other physical activities. His hypochondriacal anxiety expressed his fear of his body and his lack of identification with it.

2. Peter, a seventeen-year-old boy, was referred for psychiatric evaluation after an alarming incident. He had gotten drunk one night following an argument with his girl friend. Then, to show her how much he cared, he took his guitar to her home to serenade her. Since it was late at night, her parents were disturbed by his actions. To quiet him, they invited him into their home. Once inside, Peter demanded to see their daughter and threatened to cut off his finger or his hand as proof of his affection. He became so unruly that he had to be forcibly restrained and returned home.

Three months before this incident Peter had been involved in other troubles. He stole a car together with some friends. It was returned, and the boys admitted the theft. But, then, they ran away to avoid involving their parents, so Peter said. They broke into an empty home, stole some provisions, hid from the police, and thus compounded their difflculties with the law. Because Peter came from a good family and had a clean record, he was placed on probation. His delinquent behavior was blamed on his companions by his mother. Not until after the incident with his girl friend did she think that something could be wrong with Peter.

That something was wrong could have been seen earlier. Before any of these incidents occurred, a problem had developed in his schoolwork. After two good years in high school, Peter began to have difficulty concentrating. His studies fell off badly in his junior year. He stayed out late, started drinking, and became unmanageable. But no one seemed to show concern until the crisis occurred.

Peter's body was well built and well proportioned. His face had an innocent expression but was otherwise without feeling. This look of innocence had deceived his family. His eyes had a blank, empty quality. Despite its normal appearance, his body was tight and hard, and his movements were very uncoordinated. His knees and ankles were so stiff he could hardly bend them. His body lacked feeling, and even when he related the incident about his threat to cut off his hand he did so without feeling.

During our discussions Peter said that his sexual contact with a girl provided the only warmth he experienced and that his life was meaningless without it. Seemingly, the need for this body contact was so imperative that it overrode all rational considerations. Without it he felt so empty and unalive that moral principles had no value. I find that this condition is typical of all the delinquents I have seen. Their search for kicks is an attempt to “get a charge” into an otherwise “dead” body. Unfortunately, this search for excitement takes the form of a dangerous escapade or a rebellion against authority. The lack of normal body feeling in these young people accounts for their preoccupation with sex.

If the schizoid disturbance is not understood, delinquent behavior will continue to puzzle the authorities and the families of these young people. It will be blamed on a lack of family discipline or attributed to a moral weakness in the youth. While these explanations have some validity, they overlook the dynamics of the problem. An ego that is not grounded in the reality of body feeling becomes desperate. In its desperation it will act destructively toward itself and others.

3. Jane was a young woman of twenty-one who came into therapy following the breakup of a romantic affair. She felt lost and desperate. She sensed that something was seriously amiss with her personality, but she didn't know what it was or how to handle it. We can gain some idea of her problem from the following story:

I remember in my teens thinking I was at war with myself. Especially at night, in bed, I felt I was at war with something in me. It was very frustrating and very hopeless. I felt so confused. I didn't know whom to ask.

At eleven, I discovered my body. Before that I took it for granted. I gained a lot of weight and became self-conscious. I also began my periods at this time. The more inhibited I became, the more weight I gained and the less real I felt. I started masturbating one year later. I thought I would get pregnant or a venereal disease. I felt very guilty about it. But I would also have to masturbate before I could do anything. If I had to write a paper for school, I would procrastinate until I finally masturbated. Then I could do it.

Throughout this period I had a constant fantasy. I fantasized that I was riding a horse. Everyone else had a horse, but mine was better than theirs.

Men absolutely terrified me. I had no friends through high school and only one date in college.

Jane was at war with her sexual feelings. She could neither accept them nor repress them. The result was an intense conflict that tormented her and from which she attempted to escape through the world of fantasy. In her fantasy, the horse can be interpreted as a symbol of the body, especially the lower half. Her attempt to deny the reality of her body was only partially successful. Its feelings intruded on her consciousness and demanded satisfaction even at the price of enormous guilt.

The split in Jane's personality was also manifested on the physical level, in a very striking way. From the waist down, Jane ‘s body was heavy, hairy, and dark-hued. Her hips and thighs were large and their muscle tone was poor. Above her waist she was dainty: her chest was narrow; her shoulders sloped sharply down; her neck was long and thin; and her head was small, with regular features. The skin tone of the upper half of her body was fair. The contrast between the two halves was sharp. From the lower half of her body one had the impression of sexual maturity and womanhood that was ripe, or perhaps, in view of its flaccidity and heaviness, overripe. The upper half of her body had an innocent, childlike appearance.

Who was Jane? Was she the dainty creature riding regally on the lower half of her body or was she the horse with whom she also identified and upon whom her ego rode like a queen? Obviously, she was both, but she was unable to reconcile these two aspects of her personality.

4. The next case, though less severe in its manifestations of illness, presents another aspect of the schizoid disturbance. Sarah was a divorcee with a five-year-old son. The breakup of her marriage was quite a shock to her and brought on a deep depression. I diagnosed her character structure as schizoid although her superficial behavior gave little evidence of so severe a disorder. She expressed her problem as follows:

It's not that I'm unreal, yet I feel that my relations to people are not real. I often wonder what people think of me when I am doing something. I have delusions of grandeur. I feel that they must think I'm great. But really, I see that I can't cope. My performance doesn't measure up to my expectations.

I had been aware of an arrogance in Sarah's manner and speech which is typical of certain schizoid individuals. Sarah impressed me as one who thought she had superior qualities or superior intelligence. When I questioned her about the nature of her delusions of grandeur, she replied:

My delusion is that I have a good character in general. For example, even now, I expect people to say what a good mother I am. How well I treat my son! I was always the teacher's pet. I never disobeyed. I was a classic “goody-goody.”

Sarah was a small girl-woman with a petite, dainty face, square shoulders, and delicate body structure. Her physical appearance suggested a frightened, immature person, while her speech and manner reflected maturity and confidence. This contradiction in her personality suggested a schizoid disturbance. But there were other signs of unreality about Sarah, despite her statement to the contrary. These signs were mostly physical: the lack of contact between her eyes and mine, a frozen quality in her facial expression, a rigidity of the body structure, and a lack of coordination in body movement.

Sarah played a role, that of the “good” compliant child who did what was expected of her and did it well. Her role playing was so unconscious that she expected people to approve of her as if she were a child. Many people play certain roles in life without thereby becoming schizoid. It is a matter of degree. When the role dominates the personality, when the whole is lost in the part (the part acted out), when, as in Sarah's case, the person cannot be seen or reached behind the mask and the costume, one is justified in describing such a personality as schizoid.

In terms of symptoms each of the four cases—Jack, Peter, Jane, and Sarah—was different. In terms of the two variables which determine this illness they were alike. Each one suffered from conflicts that split the unity of his personality, and in each there was some loss of contact with reality. The most important aspect of these cases, however, was that the conflict and the withdrawal were manifested physically. Jack could describe his problems with a verbal fluency that contrasted sharply with the rigidity and immobility of his body. In Peter the conflict was expressed in the contrast between the athletic appearance of his body and its marked incoordination. Jane showed the conflict in the contrast between the two halves of her body while Sarah's sophisticated attitude contrasted sharply with the immaturity of her body.

Withdrawal from reality was manifested in each of the four patients by the lack of aliveness and the emotional unresponsiveness of the body. An observer of the schizoid individual gets the impression that he is not fully “with it.” Phrases such as “not with it” or “not all there” are commonly used to describe a schizzy quality in a person. We sense his detachment or removal. This impression stems from his vacant eyes, his masklike face, his rigid body, and his lack of spontaneity. He is not absent-minded like the proverbial professor who is absorbed in some mental preoccupation. The schizoid individual is consciously aware of his surroundings, but on the emotional or body level he is out of touch with the situation. Unfortunately, we lack an expression to denote the complement of absentmindedness. Schizzy is the only word that describes a person who is mentally present, but absent on an emotional level.

An air of unreality is the hallmark of the schizoid personality. It accounts for his “strangeness” both to us and to himself. It is also expressed in his movements. He walks mechanically, like a wooden soldier, or he floats zombie-like through life. Ernst Kretschmer's description of the physical appearance of the schizoid individual emphasizes this point.

This lack of liveliness, of immediately reacting vivacity, of psychomotor expression, is found also in the most gifted members of the group with their hypersensitive inner capacities for reaction.⁵

When an individual's appearance is so bizarre that his unreality is clearly evident, he is called psychotic, schizophrenic, or insane. The schizoid person feels his unreality as an inner emptiness and as a sensation of being removed or detached from his environment. His body may feel alien to him or almost nonexistent, as the following observation indicates.

Going to work yesterday I didn't feel my body. I felt skinny, like a bag of bones. I never felt so bodiless. I just floated in. It was terrible. I felt strange in the office. Everything felt different, unreal. I had to pull myself together to be able to work.

This graphic description of depersonalization shows both the loss of feeling of the body and the concomitant loss of contact with the environment. In other cases the tenuous contact with reality is threatened when the schizoid individual uses drugs which further dissociate his mind from his body. For example, Virginia took “pot” (marijuana) one night. This is what happened:

I had the feeling I was watching myself. I felt my body was doing things which were not connected with me. It was very frightening, so I got into bed. I became paranoid. I was afraid I might jump out of the window.

The schizoid may be said to live in limbo, that is, he is not “gone,” as is the schizophrenic, nor is he fully “with it.” He is often found on the fringes of society, where, with like kind, he feels somewhat at home. Many schizoids are the sensitive persons who become the poets, the painters, and the musicians. Others exploit the various esoteric cults which flourish in the borderlands of our society. These cults are of several kinds—those that use drugs to achieve higher states of consciousness, those in which Oriental philosophies are exploited to find a meaning in life, and those in which various body exercises offer the promise of a fuller self. But it would be a serious error to assume that the schizoid personality is found only in this milieu. He may also be the engineer who runs his life like a machine or the schoolteacher who is quiet, withdrawn, shy, and homosexual. She is the ambitious mother who tries to be very enlightened and do the right thing for her children. She is also the little girl who is bright, eager, excitable, and compulsive. As children, these people are characterized by insecurity; as adolescents by anxiety; and as adults by an inner feeling of frustration and failure. These reactions are more severe than the words imply. Their childhood insecurity is related to a feeling of being different and of not belonging. Their adolescent anxiety verges on panic and may end in terror. Their adult feeling of frustration and failure has an underlying core of despair.

APPROACHES TO THE SCHIZOID PROBLEM

The schizoid disturbance has been investigated along a number of lines, three of which are important to this study. These are the psychological, the physiological, and the constitutional. Psychology attempts to explain behavior in terms of conscious or unconscious mental attitudes. Physiology seeks the answers to disturbed attitudes in derangements of bodily functions. The constitutional approach relates personality to body structure.

Psychologically, the term “schizoid” is used to describe behavior which qualitatively resembles schizophrenia but is more or less within normal limits.⁶ The specific behavior patterns which suggest this diagnosis are summarized as follows:

1. The avoidance of any close relations with people; shyness, seclusiveness, timidity, feelings of inferiority.

2. Inability to express hostility and aggressive feelings directly— sensitivity to criticism, suspiciousness, the need for approval, tendencies to deny or distort.

3. Autistic attitudes—introversion, excessive daydreaming.

4. Inability to concentrate, feelings of being dazed or doped, sensations of unreality.

5. Hysterical outbreaks with or without apparent provocation, such as screaming, yelling, temper tantrums.

6. The inability to feel emotions, especially pleasure, and the lack of emotional responsiveness to other people, or exaggerated reactions of hyperexcitement and mania.⁷, ⁸, ⁹

Schizoid behavior, however, often appears to be normal. As Otto Fenichel points out, the schizoid individual has succeeded in “substituting pseudo-contacts of manifold kinds for a real feeling contact with other people.”¹⁰ Pseudo-contacts take the form of words which are substituted for touch. Another form of pseudo-contact is role playing, which is a substitute for an emotional commitment to a situation. The main complaints of schizoid individuals, as Herbert Weiner states, “revolve about their not being able to feel any emotions: they are estranged from others, withdrawn and detached.”¹¹

It can be shown that the psychology which characterizes the schizoid individual is related to his lack of identity. Confused as to who he is, and not knowing what he wants, the schizoid individual either detaches himself from people and withdraws into an inner world of fantasy or he adopts a pose and plays a role that seemingly will fit him into normal life. If he withdraws, symptoms of shyness, seclusiveness, suspiciousness, and unreality will predominate. If he plays a role, the outstanding symptoms will be tendencies to deny or distort, sensitivity to criticism, feelings of inferiority, and complaints of emptiness or lack of satisfaction. There may be alternations between withdrawal and activity, depression and excitement, with rapid or exaggerated mood changes. The schizoid picture presents many contrasts. Some schizoids are highly intelligent and creative, although their pursuits may be limited and unusual, while others appear dull and lead empty, docile, and inconspicuous lives.

Another view of the schizoid personality, a physiological one, is offered by Sandor Rado.¹² According to Rado the schizoid personality is characterized by two physiological defects. The first, an “integrative pleasure deficiency,” denotes an inability to experience pleasure. The second, “a sort of proprioceptive diathesis,” refers to a distorted awareness of the bodily self. The pleasure deficiency handicaps the individual in his attempt to develop an effective “action self,” or identity. Since pleasure is “the tie that really binds” (Rado), the action self that emerges in the absence of this binding power of pleasure is brittle, weak, prone to break under stress, hypersensitive. This pleasure deficiency to which Rado refers has characterized all the schizoid patients I have seen. But where Rado regards it as an inherited predisposition, I explain it in terms of the struggle for survival. Uncertain of his right to exist, and committing all his energies to the struggle for survival, the schizoid individual necessarily bypasses the area of pleasurable activity. To a man fighting for his right to exist, pleasure is an irrelevant concept.

The seeming distortion in self-perception is often the most striking feature of the schizoid personality. How can one explain Jack's remark, “I feel apart from my body as if I were outside watching myself'”? Is there a fault in Jack's self-perception or is his detachment due to the lack of something to perceive? When a body is devoid of feeling, self-perception fades out. However, it is equally true that when the ego dissociates from the body, the body becomes an alien object to the perceiving mind. We are confronted here with the same duality we described at the beginning of this chapter. The withdrawal from reality produces a split in the personality, just as every split results in a loss of contact with reality. The significance of body perception can be appreciated if one accepts Rado's remark that “the proprioceptive awareness [of the body] is the deepest internal root of language and thought.” ¹³

The weakness in the schizoid individual's self-perception is directly related to his inability to experience pleasure. Without pleasure the body functions mechanically. Pleasure keeps the body alive and promotes one's identification with it. When the body sensations are unpleasant the ego dissociates from the body. One patient said, “I made my body go dead to avoid the unpleasant feelings.”

The constitutional approach to the schizoid problem is best represented by the work of Ernst Kretschmer, who made a detailed analysis of the schizoid temperament and physique. He found that there is a close connection between the two, and that individuals with a schizoid temperament tended to have an asthenic body build, or more rarely, an athletic body build. Broadly speaking, the asthenic body can be described as long and thin, with an underdeveloped musculature, while the athletic body is more evenly proportioned and better developed muscularly. In addition Kretschmer and Sheldon¹⁴ have called attention to the presence of dysplastic elements in the schizoid body. Dysplasia refers to the fact that the different parts of the body are not harmoniously proportioned.

The four patients whose cases were discussed at the beginning of this chapter showed these typical schizoid features. Jack's body was elongated and thin, with the underdeveloped musculature of the asthenic type. Peter's body, which seemed well proportioned and muscularly developed, could be described as athletic. Jane showed dysplasia: the upper half of her body had an asthenic quality, while the lower half was amorphous and lacked definition. Sarah's body, too, had a dysplastic appearance: the upper half of her body was asthenic, in contrast to the lower half, which was markedly athletic. Her calf muscles were as developed as those of a professional dancer, although Sarah had never engaged in sports or dancing.

Body structure is important in psychiatry because it is an expression of personality. We react to a large, heavy man differently than we do to a small, wiry one. But to base the personality upon the body type is to accept a static rather than a dynamic view of the relationship between body and personality. It ignores the motility and expressiveness of the body which are the key elements in personality. The asthenic body is a meaningful classification only because it indicates the degree of an individual's muscular rigidity. The athletic body denotes a schizoid tendency only when its movements are markedly uncoordinated. Factors such as vivacity, vitality, grace, spontaneity of gesture, and physical warmth are significant because they affect self-perception and influence the feeling of identity.

Rado's view of the schizoid disturbance rests upon the hypothesis that it results from physiological dysfunctions. This is opposed to the psychoanalytic view, expressed by Silvano Arieti, that the problem is essentially psychological. Kretschmer, on the other hand, states that the schizoid condition is constitutionally determined. Whereas both Rado and Kretschmer believe that this illness has an hereditary origin, Arieti affirms that “schizophrenia [and therefore the schizoid condition] is a specific reaction to an extremely severe state of anxiety, originated in childhood, reactivated later in life.” ¹⁵

Rado, Kretschmer, and Arieti have each concentrated upon one aspect of the problem which the others regarded as secondary. Arieti concedes, for example, that “it is a well-known fact that most schizophrenics belong to the asthenic constitutional type,” ¹⁶ but he claims that it is a result of the disorder and not its cause. To avoid the argument about which comes first, we must assume that they are interrelated phenomena. The disturbances seen in body structure and physiology are an expression in the physical realm of a process which in the psychological realm appears as disorders of thought and behavior.

Psychologically, the schizoid problem is manifested in a lack of identity and, necessarily, therefore, in a loss of normal, emotional relationships to people. Physiologically, the schizoid condition is determined by disturbances in self-perception, deficiencies in the pleasure function, and disorders of respiration and metabolism. Constitutionally, the schizoid body is defective in coordination and integration. It is either too rigid or hardly held together at all. In both cases it lacks the aliveness upon which adequate self-perception depends. Without this self-perception, identity becomes confused or lost and the typical psychological symptoms appear.

A total view of the schizoid problem should present in a unified concept both the psychic and physical symptoms of the disturbance:

1 The psychological lack of identity.

2 The disturbance in self-perception.

3 The relative immobility and the diminished tone of the body surface.

The relationship between these levels of the personality may be stated as follows: The ego depends for its sense of identity upon the perception of the body. If the body is charged and responsive, its pleasure functions will be strong and meaningful, and the ego will identify with the body. In this case, the ego image will be grounded in the body image. Where the body is “unalive,” pleasure becomes impossible and the ego dissociates itself from the body. The ego image becomes exaggerated to compensate for the inadequate body image. Constitution in the dynamic sense refers to the degree of vitality and aliveness of the body.

Their relation to one another can be shown diagrammatically as a triangle.

FIG. 5 Levels of Personality

The connections between these levels of personality are illustrated in the following case. The patient was a woman who had an ego image of herself as a superior person, above average in intelligence and sensitivity. In the course of therapy this ego image was dispelled. She reported a dream in which two children, a boy and a girl, hid themselves in the basement of a building and went on a hunger strike. She related:

In my dream I feel that they are doing this out of spite. I go down into the basement, where I see their bodies lying side by side, as if they were dead, but I notice their eyes are open and their faces seem alive in contrast to the corpse-like quality of their bodies. I feel that they represent me. I have often acted spitefully in my life. I wonder if the open eyes symbolize the mind, since I feel that this is the most alive part of me.

This patient had a tall, thin body and a hollow, gaunt face which gave her appearance a cadaverous quality. She experienced her condition one day while walking with her mother in the street. She remarked, “I felt so ashamed of her that I detached myself so as not to be involved with her. I walked beside her feeling removed from her and from the world, like a ghost.” In relating this incident, the patient realized that there was an intimate connection between her dream of the corpse-like bodies, her experience of feeling like a ghost, her detachment from her body, and the appearance of her body. And then she asked me, “Why did I have to deaden myself?” The answer to this question requires an understanding of the dynamics, the mechanism, and the etiology of the schizoid problem.